Isolate and conquer
By imagining that he was a virus, Foege beat smallpox at its own game. He outsmarted the lethal microbe by zeroing in on its next potential victims — and inoculating them with a protective vaccine. This triumph provided the blueprint that public health workers used to obliterate smallpox from the planet.
In December of 1966, Foege was running a medical center in West Africa and awaiting a large shipment of smallpox vaccine. As a consultant to the CDC, he was planning a massive immunization campaign. The goal: Inoculate as many people as possible. This strategy was expensive, but conventional public health wisdom said it was the only choice; even with 90 percent coverage, outbreaks still occurred.
But the germ beat the vaccine shipment. One day, Foege got word that smallpox had hit a remote region in Eastern Nigeria. He needed to act immediately to prevent an epidemic, but adequate supplies were months away. He pretended he was the virus and schemed about how to ensure his own propagation. Then he realized the key: Strike susceptible people as quickly as possible. With this insight, he knew he needed to find those individuals — before the virus did. The race was on.
Every day at 7 p.m., the coalition of missionaries that peppered the region tuned in their ham radios to make sure no one had fallen ill or needed anything. That evening, Foege joined them. With maps laid out in front of him, he divided up the area around the outbreak. The next day, each missionary sent runners to the surrounding villages, hoping to locate smallpox cases. By that night’s radio call, the group had pinpointed the virus.
Foege’s medical team distributed a portion of the precious vaccine to those villages. The shot wouldn’t cure people who already were sick or who were well on their way to symptoms. It would, however, protect the next generation of potential victims — individuals who hadn’t yet been in contact with the virus or who had been exposed very recently.
But that was only the first step. People who carried the microbe but who still felt healthy would travel to other places and expose a new round of people. To figure out where the virus would show up next, the team analyzed market patterns. Every five days, the area’s inhabitants gathered to buy or sell goods at designated locations. Each of these markets served different villages, so Foege’s team members could trace routes the virus might take. They identified geographic areas at highest risk and made tactical strikes with the remaining vaccine.
Two weeks later, they knew they had contained the outbreak. By building a moat of resistance around the infected people, Foege had caused transmission to sputter out even though he had vaccinated only 7 to 8 percent of the area’s population.
He subsequently used this new strategy — called “surveillance and containment” — to fight smallpox in West Africa. The scheme wiped out the scourge in three years and five months—more than one and a half years quicker than planned and under budget.
After these successes, Foege took the helm of the CDC’s smallpox eradication program to combat the disease worldwide. The World Health Organization soon ‘borrowed’ him to work on the problem in India, where the virus raged uncontrollably. In October of 1973, his team conducted its first surveillance. In May of 1974, Foege sent a telegram to WHO headquarters; it said that in one state alone, the group had discovered 10,600 cases in a single week. By continually improving surveillance and vaccination strategies, they had stamped out the virus completely a year later.
In 1977, the world bid goodbye to naturally transmitted smallpox. By tracking the virus and targeting only people who had likely been exposed, Foege and the method he developed broke the chain of transmission that extended back to the very first human case in the time of Ramses V, about 1000 BC. Foege raised his glass in celebration of this tremendous achievement, but the heady joy had ebbed years earlier. Since his first “surveillance and containment” efforts had succeeded, he knew this success was possible; after that, it was just a matter of follow through. Foege had already moved on to new challenges.
Mysterious medical problems
By that year, he had returned to the United States and begun directing the CDC. In May of 1980, the agency received reports about a disturbing new phenomenon. A rash of previously healthy young women were showing up in emergency rooms in shock — high fevers, racing pulses, and dangerously low blood pressures. Medical intervention saved many of them, but some died. At first, no one could explain this frightening trend.
Under Foege’s direction, the CDC identified a risk factor for so-called “toxic shock syndrome” — a new type of tampon, which provided an unusually fertile breeding ground for a toxin-producing bacterium. The manufacturer yanked the tampons from the market, and incidence of the illness plunged.
New medical riddles continually popped up to challenge Foege. In the early 1980s several studies reported cases of Reyes syndrome — a childhood illness characterized by liver failure, trouble staying alert, and coma — associated with flu or chicken pox and aspirin. Preliminary evidence connected the disease with the aspirin rather than the infections, but the numbers weren’t high enough to nail down the potential link.
Foege struggled about how to proceed. Children were dying, but he couldn’t pin the blame on aspirin. He asked the American Academy of Pediatrics and others for advice. On one hand, he had a responsibility to tell the public what the studies were showing; on the other hand, he didn’t want to alarm parents if the painkiller posed no hazard. Furthermore, aspirin manufacturers got wind of Foege’s discussions and put enormous pressure on him not to release the results. He received phone calls at home; people told him that the CDC enjoyed a good reputation and it would be too bad if he ruined it. The manufacturers also claimed to have new information that would quash the connection with aspirin — but they never produced convincing data.
Although the studies weren’t air tight, Foege decided that the public should know what the CDC knew. He released the information. Subsequently, the agency started a study with enough people to produce clear-cut results — but they aborted it early because preliminary data established that the syndrome was related to aspirin.
AIDS followed. Even before scientists had isolated the virus, his agency devised guidelines about how to foil transmission, based on epidemiological observations: Avoid high-risk sexual practices and transfusions with blood products.
Foege extended the CDC’s reach beyond infectious disease. He brought accidental injuries, homicides, and suicide as well as chronic diseases into the purview of the agency. By including these phenomena, he expanded the CDC’s mission to include a wider swath of public health issues.
New hats, new bugs
After his tenure with the CDC ended in 1984, Foege began directing both the Carter Center and a United Nations Task Force for Child Survival. Under his leadership, the Carter Center has spearheaded efforts to obliterate river blindness. It has deployed a drug that destroys the immature form of the river blindness parasite to endemic regions of Africa and Central America. The medicine is reaching 25 million people a year; it not only is saving them from blindness, but is allowing them to reopen fertile lands next to streams that had been abandoned because of the high incidence of disease. Foege has also targeted Guinea worm — a water-born parasite that grows to lengths of two or three feet within its victims. This parasite is about to disappear from the world, largely because of the Carter Center’s activities.
In the last several years, Foege has worked with the Bill and Melinda Gates Foundation as a consultant to help the organization meet its objectives. This organization is striving to deliver vaccines to all children of the world, develop new vaccines against AIDS, tuberculosis, and malaria, and come up with tools to thwart diseases such as sleeping sickness that don’t lend themselves to vaccination. These efforts are affording children born in poor countries new possibilities of reaching adulthood, a potential not imagined a few years ago.
With his vision and inspiring leadership, William Foege is championing the fight against forgotten diseases in the developing world. He continues to usher the planet toward his goal — a state of global health equity.
by Evelyn Strauss